After Death in the GI Suite, Patient's Family Sues CRNA

[rsgillmd]

Are CRNA's really trained to perform cricothryotomy????

Training for a cric doesn't mean much. I took an airway course once which was also open to CRNAs, paramedics, and EM docs. I got a chance to practice surgical and needle crics on pig tracheas. I've subsequently practice needle crics on mannequins. If I do an awake fiberoptic, I tend to do transtracheal injections. It helps make the technique smooth and allows me to stay relatively proficient with putting a needle through the cricothyroid membrane.

However, on an obese patient your landmarks can be hard to identify. No matter how much you've practiced, combine someone with difficult landmarks and an emergency situation and you get a recipe for disaster.

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[NYRN]

As for medical clearance, I believe the current literature that came out for "low risk" outpatient procedures do not even recommend routine labs/EKGs even for ASA 3 patient. Low risk procedures include routine colonscopies/cataracts. So it's you are dammed if you do, dammed if you don't.

Medical clearance is basically hog wash if it doesn't give you the answer you need to know. As the attending anesthesiologist, I've canceled procedures even with medical clearance because I've felt the patient was experiencing symptoms and the clearance came from another provider who just wrote "moderate risk" and didn't do any further workup. Patient's lie (or forget) to tell certain doctors. So those doctors take the patients at face value and elect not to do any further studies. Had this sleep apnea patient who had "clearance" for routine breast bx (yes a male patient for breast bx). Guy was 300 plus pounds, heavy smoker, DM. He had clearance without any workup. He told me he was feeling short of breath DOS. I sent him back to his PMD. Received word the guy died of massive MI the next week before he was to have testing done. Crap like this happens all the time. You, as the anesthesiologist are ultimately responsible for proceeding with elective cases.

As a nurse and as a prior patient, I put 100% trust in anesthesia MD's because they do have the educational background and training to make these decisions. I never understood how these PMD's could "clear" a patient like this without any real workup. In some cases, it then leaves you as the "bad guy" when you cancel the case and the patient and surgeon are pissed. This is why we need anesthesiologists making these decisions, or at least mandating CRNA's to discuss the case with an attending before proceeding. I think the problem with some CRNA's, is that the ones that are intimidated by the surgeon/GI, will go ahead and do the case because they don't want to lose out on the paycheck or be fired if they cancel. The inequality in training can make the CRNA feel that the surgeon/GI "knows better" because they are the MD and they are not. When you have MD to MD disagreement, the anesthesia attending in most cases will not be intimidated by the surgeon/GI doc, and will not go ahead with a case against his/her better judgement.

 

[IlDestriero]

I think the problem with some CRNA's, is that the ones that are intimidated by the surgeon/GI, will go ahead and do the case because they don't want to lose out on the paycheck or be fired if they cancel. The inequality in training can make the CRNA feel that the surgeon/GI "knows better" because they are the MD and they are not. When you have MD to MD disagreement, the anesthesia attending in most cases will not be intimidated by the surgeon/GI doc, and will not go ahead with a case against his/her better judgement.

This is actually one of the huge advantages of the anesthesia care team model. No matter how well trained a CRNA is, they lack the perspective of medical school training. Therefore when these more complicate patients come in, or have problems intraop, they can, with the input of the surgeon/proceduralist better determine a course of action. A less knowledgable, less experienced CRNA is going to have real problems when working independently with an agressive surgeon.

 

[maceo]

As a nurse and as a prior patient, I put 100% trust in anesthesia MD's because they do have the educational background and training to make these decisions. I never understood how these PMD's could "clear" a patient like this without any real workup. In some cases, it then leaves you as the "bad guy" when you cancel the case and the patient and surgeon are pissed. This is why we need anesthesiologists making these decisions, or at least mandating CRNA's to discuss the case with an attending before proceeding. I think the problem with some CRNA's, is that the ones that are intimidated by the surgeon/GI, will go ahead and do the case because they don't want to lose out on the paycheck or be fired if they cancel. The inequality in training can make the CRNA feel that the surgeon/GI "knows better" because they are the MD and they are not. When you have MD to MD disagreement, the anesthesia attending in most cases will not be intimidated by the surgeon/GI doc, and will not go ahead with a case against his/her better judgement.

very true.. I truly believe.. and i dont care about studies. there would be a lot more morbidity and mortality if anesthesiologists were not involved in patient care.

 

[maceo]

One thing every endo suite needs but usually does not have is etCO2 monitoring. We have loads of data that says we should use it in the OR with mac cases. I see endos as an extension of the OR. We have portable etCO2 monitors that we use with nasal canulas for endos at one of our locations, we are working on it for our other places. Those things are great. They give you a more objective view of spontaneous ventilation. I also think that every endo suite should have a difficult airway equipment immediately available. That thread a few days ago about the GI hut that basically had no sux, no difficult airway equipment, no glidescope is an example. I would refuse to work at a place that did not have the above. I don't care how much they were paying me.

As for intubating the above case, I have had cases where I have done this. It is rare. Severe gastroparesis, acchlasia, active GI bleed, supraglottic mass, a history of severe obstruction with minimal sedation, are some. If you intubate every obese mal 3 airway with OSA that you see you will not be able to function in a place that does alot of endos. That is just about every patient I take care of when I get the dreaded assignment of endo hell.

Also, I have to say that I hate endos. Doing these for a day make me want to find some way to file for disability. But the fact is I do feel like it is best that we are involved. For the ASA 1 pt that is thin and healthy it is not such a big deal. But I may see one or two of those in a day. Most patients are like the above who's staple diet is Big Mac's and french fries followed by an oreo flurry for desert so that they can wash down their 200mg am dose of oxycontin for their fibromyalgia. They have OSA, a BMI of more than 50, and are there because of dysphagia. Think about it, dysphagia and obesity, the two just don't go together.

I dont agree that etco2 monitoring is essential in the gi suite, however monitoring the respirations continually is mandatory for successful outcomes. Put your hand over the mouth frequently to feel the warm exhalation of the patient. look at the up and down movement of the chest look at the abdomen for paradoxical abdominal resps. These are essential. I feel etco2 is the lazy way out of it. In this population the above measures needs to be carried out every 2 mins or so. I do agree with you about the sux and difficutla airway. In the event of emergency you need those.

 

[pd4emergence]

I dont agree that etco2 monitoring is essential in the gi suite, however monitoring the respirations continually is mandatory for successful outcomes. Put your hand over the mouth frequently to feel the warm exhalation of the patient. look at the up and down movement of the chest look at the abdomen for paradoxical abdominal resps. These are essential. I feel etco2 is the lazy way out of it. In this population the above measures needs to be carried out every 2 mins or so. I do agree with you about the sux and difficutla airway. In the event of emergency you need those.

These cases go to sh$t quickly. Especially in the orca fat population. To me those folks desat like a stone. The etco2 monitors help especially when I medically direct CRNA's (some) who think that chest movement is equivalent to ventilation. It would not be as big of a deal if it was me in there doing the case by myself. I know when the patient is breathing. I also think etco2 monitoring helps identify obstruction more quickly. I am not too computer savy otherwise i would post some links but look up the mac data in regards to etco2 monitoring. I am fighting to get these monitors in all of the endo rooms that we staff. I am not saying they are essential, but I do some with and some without and find that things seem to go smoother when I do them with.

 

[pd4emergence]

Are CRNA's really trained to perform cricothryotomy????

I still have CRNA's tell me that they are trained to do lines and could put one in even though where I work these particular CRNA's haven't put in a CVL since they started working here 10 years ago (we don't let them). The national CRNA training requirements are pitifully low in regards to procedures. They may say they are trained to do it but that really means nothing.

 

[leaverus]

I still have CRNA's tell me that they are trained to do lines and could put one in even though where I work these particular CRNA's haven't put in a CVL since they started working here 10 years ago (we don't let them). The national CRNA training requirements are pitifully low in regards to procedures. They may say they are trained to do it but that really means nothing.

That's nothing. Our CRNAs tell me they're trained to be physicians.

 

[Paseo Del Norte]

As a nurse and as a prior patient, I put 100% trust in anesthesia MD's because they do have the educational background and training to make these decisions. I never understood how these PMD's could "clear" a patient like this without any real workup. In some cases, it then leaves you as the "bad guy" when you cancel the case and the patient and surgeon are pissed. This is why we need anesthesiologists making these decisions, or at least mandating CRNA's to discuss the case with an attending before proceeding. I think the problem with some CRNA's, is that the ones that are intimidated by the surgeon/GI, will go ahead and do the case because they don't want to lose out on the paycheck or be fired if they cancel. The inequality in training can make the CRNA feel that the surgeon/GI "knows better" because they are the MD and they are not. When you have MD to MD disagreement, the anesthesia attending in most cases will not be intimidated by the surgeon/GI doc, and will not go ahead with a case against his/her better judgement.

Candidate for post of the year?

 

[CrazyJake]

Working with a CRNA today and I asked her the difference b/n a bronchospasm and laryngospasm.

Her reply - 1 involves the bronchioles which are lower and the other the larynx which is higher up in the body.

I then asked, what do you do to treat these? Her reply, after a long pause, I just hold pressure on the bag and hope that works. I think you can give Succ for 1 of the spasms, but I always get this confused. If you can, just page the Anesthesiologist.

I know there are great CRNA's, but this is what I was learning from today.

CJ

 

[IlDestriero]

Working with a CRNA today and I asked her the difference b/n a bronchospasm and laryngospasm.

Her reply - 1 involves the bronchioles which are lower and the other the larynx which is higher up in the body.

I then asked, what do you do to treat these? Her reply, after a long pause, I just hold pressure on the bag and hope that works. I think you can give Succ for 1 of the spasms, but I always get this confused. If you can, just page the Anesthesiologist.

I know there are great CRNA's, but this is what I was learning from today.

CJ

Why was a resident working with or "learning from" a CRNA?
I had CRNAs at my program. We NEVER worked with them. Not counting helping them out with lines or blocks. If you are being "trained" by CRNAs, something is really wrong there. I hope I am reading something into your post that is misleading...

 

[leaverus]

Why was a resident working with or "learning from" a CRNA?
I had CRNAs at my program. We NEVER worked with them. Not counting helping them out with lines or blocks. If you are being "trained" by CRNAs, something is really wrong there. I hope I am reading something into your post that is misleading...

I hope so, too. Residents learning from CRNAs is a travesty - if it's true, our specialty is seriously going down the toilet. How sad.

 

[CrazyJake]

Haven't started my Anesthesia training yet, this is just a month long intern elective and happened to be in a room with one of the CRNA's learning some of the basics. We have more CRNA's than Anesthesiologist at my hospital...although this is rapidly changing, per the Anesthesia group.

In her defense, I did learn today...but I would think the mgmt of a bronchospasm vs laryngospasm would be a core competency to practice.

 

[CrazyJake]

I haven't started my official Anesthesia training. This is just an month elective before I start at my Anesthesia program.

We have a lot of CRNA's at my intern program, but that is rapidly changing according to the Anesthesiologist.

In the CRNA's defense, I did learn a good deal today and every day is a plus before I officially start, but I kinda thought bronchospasm vs laryngospasm was a core competency for any anesthesia provider to fully understand.

 

[sevo85288]

That's nothing. Our CRNAs tell me they're trained to be physicians.

That's nothing. Our CRNAs told the surgeon she could do the AAA repair.

 

[sevo85288]

Do yourself a favor and don't learn from CRNA. They have defected knowledge. Seriously. Old wive's tales propagated as science. Ask them some basic physiology questions or basic ventilation questions...

I haven't started my official Anesthesia training. This is just an month elective before I start at my Anesthesia program.

We have a lot of CRNA's at my intern program, but that is rapidly changing according to the Anesthesiologist.

In the CRNA's defense, I did learn a good deal today and every day is a plus before I officially start, but I kinda thought bronchospasm vs laryngospasm was a core competency for any anesthesia provider to fully understand.

 

[deleted126335]

I hope so, too. Residents learning from CRNAs is a travesty - if it's true, our specialty is seriously going down the toilet. How sad.

The reality is experienced CRNAs have the ability to teach plenty to junior residents. The hyperbole on this thread is unbecoming.

 

[leaverus]

The reality is experienced CRNAs have the ability to teach plenty to junior residents. The hyperbole on this thread is unbecoming.

How is what i said hyperbole?? In any case, i don't disagree with you - there are many excellent CRNAs out there, who probably would've been great physicians had they chosen that route and may very well be good teachers. However, "the reality is" - as you say - that there are more crappy ones than good ones and there's no way for a green resident to know whether they're learning from one of the good ones or, more than likely, the bad ones. IMHO, residents should learn from other docs - senior residents and attending anesthesiologists. And while there are crappy MD/DOs, too, that's unusual at a good training program. But, i'm not in residency anymore, so the guys who are can choose to learn from whomever they wish.

 

[Gern Blansten]

The reality is experienced CRNAs have the ability to teach plenty to junior residents. The hyperbole on this thread is unbecoming.

The fact is that the RRC forbids it. It will lead to probation for the program if identified as a frequent occurrence.

 

[lakersbaby]

just came across this blog and heres one of the comments that almost made me throw my computer out the window.

Anonymous said...
Let's not forget that the first 4 years of an MD's education in the US is completely useless. They need a four year degree in English Lit before going to ONLY 4 years of medical school. The residancy is only for their specialty training and they get paid for it. I know MDs who make 7 figures a year. Yeah, that was not a typo. A CRNA may require 8 years of education, but 6 is totally dedicated to the study of health care. An MD only has 4 years of health care education.

http://califmedicineman.blogspot.com/2007/04/physicians-upset-about-nurse.html

 

[deleted126335]

The fact is that the RRC forbids it. It will lead to probation for the program if identified as a frequent occurrence.

I am not talking about residents being supervised with a crna as their "staff" for the case, I am talking about learning from a clinician who has more experience than they do. CRNAs who work every day doing major peds or cardiac for years in an academic medical center can be a helluva resource to a resident.

 

[Arch Guillotti]

I am not talking about residents being supervised with a crna as their "staff" for the case, I am talking about learning from a clinician who has more experience than they do. CRNAs who work every day doing major peds or cardiac for years in an academic medical center can be a helluva resource to a resident.

And a lot of them are very good at performing tasks and pattern recognition, but that's about it.

 

[jwk]

just came across this blog and heres one of the comments that almost made me throw my computer out the window.

Anonymous said...
Let's not forget that the first 4 years of an MD's education in the US is completely useless. They need a four year degree in English Lit before going to ONLY 4 years of medical school. The residancy is only for their specialty training and they get paid for it. I know MDs who make 7 figures a year. Yeah, that was not a typo. A CRNA may require 8 years of education, but 6 is totally dedicated to the study of health care. An MD only has 4 years of health care education.

http://califmedicineman.blogspot.com/2007/04/physicians-upset-about-nurse.html

Just to be clear - CRNA's do NOT require 8 years of education, and the idea that six are "totally dedicated to the study of health care" is simply a lie with no basis in fact.

 

[Mman]

just came across this blog and heres one of the comments that almost made me throw my computer out the window.

Anonymous said...
Let's not forget that the first 4 years of an MD's education in the US is completely useless. They need a four year degree in English Lit before going to ONLY 4 years of medical school. The residancy is only for their specialty training and they get paid for it. I know MDs who make 7 figures a year. Yeah, that was not a typo. A CRNA may require 8 years of education, but 6 is totally dedicated to the study of health care. An MD only has 4 years of health care education.

http://califmedicineman.blogspot.com/2007/04/physicians-upset-about-nurse.html

CRNA's have 4 years of undergrad and between 18-27 months of CRNA school. That's it.

And knowing lots of CRNAs and tons of CRNA students, I can assure you that a lot of my upper level classes in undergrad were far more advanced than anything they get in their entire career. Not even close. Genetics, pharmacology, physiology,.... Throw in 8 more years after that and it's equivalent to comparing a PhD to somebody with a bachelors degree and arguing it's remotely comparable.

In CRNA school, they learn the very basics of the science behind things they are using in the OR but that's about it. What they do get is good training at the nuts and bolts of anesthesia. Checking a macine, being efficient turning a room over, waking a patient up quickly, etc. The only understanding they have of the physiology of disease and how that interacts in the OR is what they gain from experience over time and there is lots of individual variability in how much of that they pick up over time. The vast, vast majority of CRNAs can do a good to great job in the OR with just about anything if they have a competent anesthesiologist directing their care.

 

[CVRN]

CRNA's have 4 years of undergrad and between 18-27 months of CRNA school. That's it.

http://webapps.aana.com/AccreditedP...vMenu_TSMenuTargetType=5&ucNavMenu_TSMenuID=6

Here is a link to the list of accredited CRNA programs. Through a brief search, I cannot find a single program that is less than 24 months. You'll see that 24-36 months is a more accurate description of the length of CRNA school.

 

[pd4emergence]

http://webapps.aana.com/AccreditedP...vMenu_TSMenuTargetType=5&ucNavMenu_TSMenuID=6

Here is a link to the list of accredited CRNA programs. Through a brief search, I cannot find a single program that is less than 24 months. You'll see that 24-36 months is a more accurate description of the length of CRNA school.

So what's your point? 24-36 months of calling someone else when the sh$t hits the fan. Here is how to deal with SRNA's (resident SRNA's as they like to call themselves): teach them to sit on a stool, follow your anesthetic plan, and when to call you. That is all they need to know. No lines, no regional, no procedures. There is no need for them to know how to do anything else.

 

[leaverus]

teach them to sit on a stool, follow your anesthetic plan, and when to call you. That is all they need to know. No lines, no regional, no procedures. There is no need for them to know how to do anything else.

+1

 

[pgg]

Edit - wrong thread.

 

[pgg]

No lines, no regional, no procedures. There is no need for them to know how to do anything else.

I have two kinds of jobs - active duty Navy, and some civilian moonlighting in a recently out-opted state (the great state of California, aka the Greece of North America).

At my military day job, I must confess to doing my best to teach the CRNAs what I know. For better or worse, they get deployed to remote hostile places where there's no anesthesiologist to call. Knowing they'll be taking care of our Marines I can't in good conscience not try to help prepare them. Part of that is line placement and more advanced regional techniques including indwelling catheters. So when they get out of the military and hit the civilian market with independence chips on their shoulders, some of the blame is mine. Sorry 'bout that.


As for my time at the civilian hospitals ... it's funny how in this opt-out state, when I'm the backup call guy and a someone needs a line or a block or a sick ASA 4E comes in through the ER, the independent CRNAs don't hesitate to call me in. Somehow independence is less desirable then. (I literally JUST put in a line in an IV-access-challenged former IV drug abuser so the CRNA could do the case.)

Also as the backup weekend call guy, I'll field calls from these independent providers who ask if they should do a case at all. This is even more worrisome to me

• A minority have a startlingly poor ability to make the go/no-go call based on more than gut feeling or a "looks sick" assessment. This is clear from the "should I do this case" calls I get. A few just have absolutely no clue what matters and what doesn't.
• Often they've intuitively sensed they shouldn't do the case but can't articulate why not to the surgeon. As nurses on unequal footing with doctor surgeons who are pushing to get the case done, I suspect they get subtly or overtly bullied into doing some cases that should wait. Here, by definition they aren't calling me to ask the "should I do this case" question so I have no idea how often this happens - but I bet it's not "never" ...

But $$$ talks, and the AANA has spent it, so what can you do?

 

[proteus2025]

So what's your point? 24-36 months of calling someone else when the sh$t hits the fan. Here is how to deal with SRNA's (resident SRNA's as they like to call themselves): teach them to sit on a stool, follow your anesthetic plan, and when to call you. That is all they need to know. No lines, no regional, no procedures. There is no need for them to know how to do anything else.

This statment is far removed from reality

 

[SleepIsGood]

At my military day job, I must confess to doing my best to teach the CRNAs what I know. For better or worse, they get deployed to remote hostile places where there's no anesthesiologist to call. Knowing they'll be taking care of our Marines I can't in good conscience not try to help prepare them. Part of that is line placement and more advanced regional techniques including indwelling catheters. So when they get out of the military and hit the civilian market with independence chips on their shoulders, some of the blame is mine. Sorry 'bout that.
[/url]?

Regional man....I agree the marine's need it. But then the marines(army) should pay you guys (physicians) enough to incentivize you guys to treat these patients. I can think of tons of residents that would do military medicine if it was an economically appealign thing to do. By just teaching the CRNAs, you are reaffirming the Army's action of not incentivizing physicians.

I hear what you are saying. But teaching CRNAs regional as well is just asking for a lot..They have no clue about anatomy the way physicians do. Ultimately safety is a product of knowledge, which THEY dont have as it relates to anatomy and such..

 

[Laryngophed]

Regional man....I agree the marine's need it. But then the marines(army) should pay you guys (physicians) enough to incentivize you guys to treat these patients. I can think of tons of residents that would do military medicine if it was an economically appealign thing to do. By just teaching the CRNAs, you are reaffirming the Army's action of not incentivizing physicians.

I hear what you are saying. But teaching CRNAs regional as well is just asking for a lot..They have no clue about anatomy the way physicians do. Ultimately safety is a product of knowledge, which THEY dont have as it relates to anatomy and such..

I don't think the issue for pgg is the money, it's the fact that the military will deploy these CRNAs and treat them as independent practioners. Because of this, pgg feels obligated to provide them with all of the training he can because these Marines are going to need the best care possible. I don't think it's a matter of it not being worth the time/trouble for pgg and colleagues to treat the soldiers, it is a matter of being physically separated from them and the only provider around being the CRNAs.

At least, that was my interpretation of his post.

 

[Arch Guillotti]

This statment is far removed from reality

goodbye troll (again)

 

[SleepIsGood]

I don't think the issue for pgg is the money, it's the fact that the military will deploy these CRNAs and treat them as independent practioners. Because of this, pgg feels obligated to provide them with all of the training he can because these Marines are going to need the best care possible. I don't think it's a matter of it not being worth the time/trouble for pgg and colleagues to treat the soldiers, it is a matter of being physically separated from them and the only provider around being the CRNAs.

At least, that was my interpretation of his post.

I understand what he's saying. I'm not necessarily blaming him.

But regardless, the military SHOULDNT deploy the CRNAs alone. They do it because they have in the past and anesthesiologists allow it. Anesthesiologists should block that sort of thing from happening.

For example, if a patient has a severe wound in the field..the surgeons dont let the army deploy PAs to the field. You have medics,etc 'stabilize' patients and bring them to the hospitals.

All I'm saying is that there's nothing that EMERGENT. Pain can be treated with other modalities atleast initially. IV narcotics,etc can be used to stabilize for transport. Even ketamine is used to stabilize the patient's pain(according to one of the army officiers at the last ASRA meeting this is becoming very popular). Get the patient/marine to the hospital ASAP for a physician to evaluate/perform a block. I just thnk it's unwise to teach the trade to individuals constantly trying to undermine you..

 

[pgg]

Regional man....I agree the marine's need it. But then the marines(army) should pay you guys (physicians) enough to incentivize you guys to treat these patients. I can think of tons of residents that would do military medicine if it was an economically appealign thing to do. By just teaching the CRNAs, you are reaffirming the Army's action of not incentivizing physicians.

Believe me I've wrestled with these points myself, and as much as I personally like and respect the CRNAs I work with, I remain uncomfortable with the overall concept of independent practice - even within the military. Despite the fact (well, my opinion) that military CRNAs are on the whole better and more consistently trained than their civilian counterparts. There are days when I, with the benefit of medical school and residency, feel barely competent to do what I do. I can only imagine how they feel some days.

However for a multitude of reasons the military has and will continue to utilize CRNAs as independent practitioners. That is not going to change, ever. To give you some perspective, to this day the military feels residency training is unnecessary for physicians to be employed in primary care positions. 13 years ago when I was getting ready to sign up the Navy said the general medical officer was being phased out ... well, I spent 3 years as a GMO after a transitional internship, and 80% of those billets are still there today. The military already pays its specialist physicians a wage so incredibly far below market that it's the driving force behind over 90% leaving service when their scholarship obligations are up. This is also not going to change, ever - retention is an explicitly stated anti-goal because retirement benefits cost so much, and it's easy to recruit destitute medical students with paltry $20K signup bonuses when they're staring down the barrel of some for-profit school with $40K/year tuition.

So the environment isn't going to change. The choice we have in the military is between making an aggressively fruitless stand on principle (while alienating and generally being dickish toward good people who are also serving their country for less than a fair market wage), and doing what we can to help them provide the best care possible in distant, isolated, austere conditions. And ultimately that means teaching and training military CRNAs to know more and do more than civilian CRNAs.

When the Marine comes in, down a couple liters of blood after getting shot, they are going to put in a line. When the Marine who stepped on a mine is awaiting an evacuation flight, minus a foot, they're going to give him a block. Idly wishing an anesthesiologist was there is not as productive as helping them prepare to do these things safely.

That some marginal AANA-donating civilian CRNA who trained in an Idaho strip mall surgicenter then decides she should be able to practice independently in the United States because of the example set by military CRNAs ... well, that's another issue entirely.

 

[jwk]

I understand what he's saying. I'm not necessarily blaming him.

But regardless, the military SHOULDNT deploy the CRNAs alone. They do it because they have in the past and anesthesiologists allow it. Anesthesiologists should block that sort of thing from happening.

For example, if a patient has a severe wound in the field..the surgeons dont let the army deploy PAs to the field. You have medics,etc 'stabilize' patients and bring them to the hospitals.

All I'm saying is that there's nothing that EMERGENT. Pain can be treated with other modalities atleast initially. IV narcotics,etc can be used to stabilize for transport. Even ketamine is used to stabilize the patient's pain(according to one of the army officiers at the last ASRA meeting this is becoming very popular). Get the patient/marine to the hospital ASAP for a physician to evaluate/perform a block. I just thnk it's unwise to teach the trade to individuals constantly trying to undermine you..

Someone correct me if I'm wrong, but aren't physicians and nurses in the armed forces under different commands, as in Medical Corps and Nurse Corps?

 

[pgg]

I understand what he's saying. I'm not necessarily blaming him.

But regardless, the military SHOULDNT deploy the CRNAs alone. They do it because they have in the past and anesthesiologists allow it. Anesthesiologists should block that sort of thing from happening.

I suppose they could block it (I don't say "we" because I lack the rank and position to influence that kind of thing) ... with the consequence being that CRNAs wouldn't deploy and anesthesiologists would deploy 2x as often.

It's one thing to assert that you won't teach CRNAs on principle, because it basically costs you nothing. If it cost you another 7 month trip to a 7' x 10' apartment in a shipping containter in a desert, 6 months after you got back from the last one ... Well, bravo if you can make that stand.

For example, if a patient has a severe wound in the field..the surgeons dont let the army deploy PAs to the field. You have medics,etc 'stabilize' patients and bring them to the hospitals.

Surgery is another beast. No one can make even a weak argument that a PA should perform surgery unsupervised.

I'm fully aware of the fact - and maybe even some hypocrisy - that military anesthesiologists will happily share the deployment burden with CRNAs while military surgeons have no midlevel counterpart to share theirs.

All I'm saying is that there's nothing that EMERGENT. Pain can be treated with other modalities atleast initially. IV narcotics,etc can be used to stabilize for transport. Even ketamine is used to stabilize the patient's pain(according to one of the army officiers at the last ASRA meeting this is becoming very popular). Get the patient/marine to the hospital ASAP for a physician to evaluate/perform a block.

The problem is that many of these "hospitals" don't have anesthesiologists. Lots of those locations will have some kind of surgeon (which in some cases may even be an obstetrician!) who does quick, life or limb saving work with a CRNA before the patient is evacuated further.

I'm not sure I'd agree that a patient should be denied (for example) a CRNA-placed popliteal or axillary block while awaiting transport to the major regional facility. There is real potential for such transport to be substantially delayed in a combat zone, for a number of reasons. It doesn't happen often thankfully.

I just thnk it's unwise to teach the trade to individuals constantly trying to undermine you..

I don't disagree, but it's hard to justify making stands under these circumstances for purely political goals or future compensation reasons. Also, within the military, there's usually less of an us vs. them relationship between anesthesiologists and CRNAs. That's not to say there's never any friction ... just that being in the military is one thing that tends to put us on the same side.

 

[Laryngophed]

I understand what he's saying. I'm not necessarily blaming him.

But regardless, the military SHOULDNT deploy the CRNAs alone. They do it because they have in the past and anesthesiologists allow it. Anesthesiologists should block that sort of thing from happening.

For example, if a patient has a severe wound in the field..the surgeons dont let the army deploy PAs to the field. You have medics,etc 'stabilize' patients and bring them to the hospitals.

All I'm saying is that there's nothing that EMERGENT. Pain can be treated with other modalities atleast initially. IV narcotics,etc can be used to stabilize for transport. Even ketamine is used to stabilize the patient's pain(according to one of the army officiers at the last ASRA meeting this is becoming very popular). Get the patient/marine to the hospital ASAP for a physician to evaluate/perform a block. I just thnk it's unwise to teach the trade to individuals constantly trying to undermine you..

Ahh, sorry. I misread/misunderstood your previous post. Sorry about that. I see what you are saying now and I agree that they (CRNAs) shouldn't be used as solo practitioners. I'm not entirely certain what recourse the docs have in pressuring the military to reconsider the position but I'm totally in agreement that teaching your "competition" (for want of a better a word. In the military world, I think it would be frowned upon to view anyone wearing the Stars and Stripes as competition whilst that is the reality in the civilian world) your craft so they can use it against you out in civvie land. That's a tough spot for the milmed docs.

 

[pgg]

Someone correct me if I'm wrong, but aren't physicians and nurses in the armed forces under different commands, as in Medical Corps and Nurse Corps?

Yes, but that has very little bearing on day-to-day working relationships.

Any negotiation between the MC and NC regarding who fills a deployment slot is conducted at high levels, way out of the peons' view or influence.

 

[Coastie]

Dude,

Why train the military militant crnas in this fashion?

Let the military chalk it up and provide anesthesiologists. This kind of education your providing is biting us all in the rear..You could use the same argument for any CRNA training, civi or mil.

I have two kinds of jobs - active duty Navy, and some civilian moonlighting in a recently out-opted state (the great state of California, aka the Greece of North America).

At my military day job, I must confess to doing my best to teach the CRNAs what I know. For better or worse, they get deployed to remote hostile places where there's no anesthesiologist to call. Knowing they'll be taking care of our Marines I can't in good conscience not try to help prepare them. Part of that is line placement and more advanced regional techniques including indwelling catheters. So when they get out of the military and hit the civilian market with independence chips on their shoulders, some of the blame is mine. Sorry 'bout that.


As for my time at the civilian hospitals ... it's funny how in this opt-out state, when I'm the backup call guy and a someone needs a line or a block or a sick ASA 4E comes in through the ER, the independent CRNAs don't hesitate to call me in. Somehow independence is less desirable then. (I literally JUST put in a line in an IV-access-challenged former IV drug abuser so the CRNA could do the case.)

Also as the backup weekend call guy, I'll field calls from these independent providers who ask if they should do a case at all. This is even more worrisome to me

• A minority have a startlingly poor ability to make the go/no-go call based on more than gut feeling or a "looks sick" assessment. This is clear from the "should I do this case" calls I get. A few just have absolutely no clue what matters and what doesn't.
• Often they've intuitively sensed they shouldn't do the case but can't articulate why not to the surgeon. As nurses on unequal footing with doctor surgeons who are pushing to get the case done, I suspect they get subtly or overtly bullied into doing some cases that should wait. Here, by definition they aren't calling me to ask the "should I do this case" question so I have no idea how often this happens - but I bet it's not "never" ...

But $$$ talks, and the AANA has spent it, so what can you do?

 

[Coastie]

So what's your point? 24-36 months of calling someone else when the sh$t hits the fan. Here is how to deal with SRNA's (resident SRNA's as they like to call themselves): teach them to sit on a stool, follow your anesthetic plan, and when to call you. That is all they need to know. No lines, no regional, no procedures. There is no need for them to know how to do anything else.

Yep.

CRNAs are just like any other nurse: follow the physician's orders, as a team, and help the patient.

Leave the medicine to the experts.

 

[Coastie]

Surgeons, not CRNAs, can throw in that line.

Or medics.

Or GMOs.

Oh, and throw in a real line, like a couple of 14s, into the private, not a SC/IJ/Fem TLC.

Believe me I've wrestled with these points myself, and as much as I personally like and respect the CRNAs I work with, I remain uncomfortable with the overall concept of independent practice - even within the military. Despite the fact (well, my opinion) that military CRNAs are on the whole better and more consistently trained than their civilian counterparts. There are days when I, with the benefit of medical school and residency, feel barely competent to do what I do. I can only imagine how they feel some days.

However for a multitude of reasons the military has and will continue to utilize CRNAs as independent practitioners. That is not going to change, ever. To give you some perspective, to this day the military feels residency training is unnecessary for physicians to be employed in primary care positions. 13 years ago when I was getting ready to sign up the Navy said the general medical officer was being phased out ... well, I spent 3 years as a GMO after a transitional internship, and 80% of those billets are still there today. The military already pays its specialist physicians a wage so incredibly far below market that it's the driving force behind over 90% leaving service when their scholarship obligations are up. This is also not going to change, ever - retention is an explicitly stated anti-goal because retirement benefits cost so much, and it's easy to recruit destitute medical students with paltry $20K signup bonuses when they're staring down the barrel of some for-profit school with $40K/year tuition.

So the environment isn't going to change. The choice we have in the military is between making an aggressively fruitless stand on principle (while alienating and generally being dickish toward good people who are also serving their country for less than a fair market wage), and doing what we can to help them provide the best care possible in distant, isolated, austere conditions. And ultimately that means teaching and training military CRNAs to know more and do more than civilian CRNAs.

When the Marine comes in, down a couple liters of blood after getting shot, they are going to put in a line. When the Marine who stepped on a mine is awaiting an evacuation flight, minus a foot, they're going to give him a block. Idly wishing an anesthesiologist was there is not as productive as helping them prepare to do these things safely.

That some marginal AANA-donating civilian CRNA who trained in an Idaho strip mall surgicenter then decides she should be able to practice independently in the United States because of the example set by military CRNAs ... well, that's another issue entirely.

 

[Narcotized]

And a lot of them are very good at performing tasks and pattern recognition, but that's about it.

Very very astute observation.

 

[pgg]

Surgeons, not CRNAs, can throw in that line.

The surgeons have other work to do.

Or medics.

Seriously, you'd rather have an IJ placed by a 19-year-old medic with the equivalent of EMT training and ZERO experience with lines? Isn't that taking the CRNA turf war a little bit far?

Or GMOs.

It's the exception, not the rule, for GMOs to be colocated with surgical teams. Even when they are, hanging out at the FRSS isn't their primary duty. During my 2nd deployment as a GMO, the majority of my time during operations was spent doing echelon 1 duty (frequently watching casualties overfly me straight to the FRSS).

Oh, and throw in a real line, like a couple of 14s, into the private, not a SC/IJ/Fem TLC.

Who said anything about TLCs? Yeah yeah, the 20 cm 18/20 gauge tube you get from a TLC isn't appropriate; a pair of 14s is better for volume. But are you really arguing that big neck lines don't have a place in trauma?

Why train the military militant crnas in this fashion?

Let the military chalk it up and provide anesthesiologists.

They will never do that. If we didn't train CRNAs, they'd simply accept the consequences of less capable care from CRNAs in combat zones. After all, the Feres doctrine grants absolute immunity should there be an adverse outcome. Whether we teach them or not, there will come a day when they're called upon to put something large in an IJ. Seems like the right thing to do is try to minimize the chances they'll drop a lung or dilate a carotid. If the patient dies the military will chalk it up to a combat death.

Only we will be wondering if a little less political grandstanding could've helped avoid a procedure complication.

This kind of education your providing is biting us all in the rear..You could use the same argument for any CRNA training, civi or mil.

No, the argument is substantially different - and that's the point of my posts here.

The argument against teaching CRNAs in the civilian world is equal parts politics/turf and quality of care.

Those economic and political incentives aren't part of the equation in the military. You think some wounded lance corporal who shows up at a FRSS staffed by a CRNA is going to be comforted by the knowledge that military doctors withheld training from that CRNA for turf protection reasons?

The military makes a number of compromises regarding the standard of care available in forward positions. CRNA vs anesthesiologist is only one of them.

If I was a civilian I'd decline to teach CRNAs out of professional self-preservation. In the military I personally won't make that stand.

 

[BLADEMDA]

That some marginal AANA-donating civilian CRNA who trained in an Idaho strip mall surgicenter then decides she should be able to practice independently in the United States because of the example set by military CRNAs ... well, that's another issue entirely


PGG

 

[pd4emergence]

I have two kinds of jobs - active duty Navy, and some civilian moonlighting in a recently out-opted state (the great state of California, aka the Greece of North America).

At my military day job, I must confess to doing my best to teach the CRNAs what I know. For better or worse, they get deployed to remote hostile places where there's no anesthesiologist to call. Knowing they'll be taking care of our Marines I can't in good conscience not try to help prepare them. Part of that is line placement and more advanced regional techniques including indwelling catheters. So when they get out of the military and hit the civilian market with independence chips on their shoulders, some of the blame is mine. Sorry 'bout that.


As for my time at the civilian hospitals ... it's funny how in this opt-out state, when I'm the backup call guy and a someone needs a line or a block or a sick ASA 4E comes in through the ER, the independent CRNAs don't hesitate to call me in. Somehow independence is less desirable then. (I literally JUST put in a line in an IV-access-challenged former IV drug abuser so the CRNA could do the case.)


Also as the backup weekend call guy, I'll field calls from these independent providers who ask if they should do a case at all. This is even more worrisome to me

• A minority have a startlingly poor ability to make the go/no-go call based on more than gut feeling or a "looks sick" assessment. This is clear from the "should I do this case" calls I get. A few just have absolutely no clue what matters and what doesn't.
• Often they've intuitively sensed they shouldn't do the case but can't articulate why not to the surgeon. As nurses on unequal footing with doctor surgeons who are pushing to get the case done, I suspect they get subtly or overtly bullied into doing some cases that should wait. Here, by definition they aren't calling me to ask the "should I do this case" question so I have no idea how often this happens - but I bet it's not "never" ...

But $$$ talks, and the AANA has spent it, so what can you do?

pgg,
I grew up around the military. I still hear the stories from family and patients. I live in an area where we are very dependent on the base here. I don't think you can do anything else in regards to training military NA's. There are simply not enough anesthesiologists to go around and there never will be. The NA's will be deployed and at times will be by themselves. No way around it. I am in a situation where I can dictate what we do with our SRNA's and CRNA's and what we say is the way it will be. I think the military is a whole different animal. How many times have you had a CRNA outrank you? Who is in charge then? Its gotta be awkward at times. Part of my reasoning for not teaching lines and regional is that they just don't need to know it. It should be the most trained, most experienced person doing an invasive procedure. In the civilian world that is me. Not so much in middle of nowhere Afghanistan. Thank you for your service. Stay safe.

 

[IlDestriero]

PGG,
I've been there brother (as you know). You're doing the right thing, the BEST thing for your patient population. Now, I usually don't let the CRNAs even put in IVs. But that's here in the real world. My corpsmen could put an 16 in anyone! When the stuff hit the fan, I knew that at least they could get a liter in to stabilize them for transport.
Stay safe.

 

[pd4emergence]

This statment is far removed from reality

Not where I work. This statement is reality for me.

 

[SleepIsGood]

See the only issue is this.

Those "military CRNAs" are the ones that usually come out into the civilian world and become the "militant' CRNAs. They then go on to brag that in the military "I put this line in and that line in, we're just as good as anesthesiologists".

See that's the issue. It's an issue because they then 'infect' their colleagues in the civilian world to think the same way.

 

[Arch Guillotti]

See the only issue is this.

Those "military CRNAs" are the ones that usually come out into the civilian world and become the "militant' CRNAs. They then go on to brag that in the military "I put this line in and that line in, we're just as good as anesthesiologists".

See that's the issue. It's an issue because they then 'infect' their colleagues in the civilian world to think the same way.

No way.

Plenty of nurses who have nothing to do with the military have this mentality. Many seem to be male and many seem to be recent graduates.

The vast majority of nurses I work with are a pleausre to deal with and we all get along very well.

The "militant" subset is very small however this mentality appears to drive the AANA.